J Orthop Sci (2005) 10:353–359
DOI 10.1007/s00776-005-0917-5

Original article
Validation of the Japanese Society for Surgery of the Hand version of
the Disability of the Arm, Shoulder, and Hand questionnaire
Toshihiko Imaeda1, Satoshi Toh2, Yasushi Nakao3, Jun Nishida4, Hitoshi Hirata5, Masateru Ijichi6,
Chizuko Kohri7, and Akira Nagano8 for the Impairment Evaluation Committee, Japanese Society for
Surgery of the Hand
1

Department of Public Health, Fujita Health University School of Medicine, Tokoake, Japan
Department of Orthopaedic Surgery, Hirosaki University School of Medicine, 5 Zaifu-cho, Hirosaki 036-8562, Japan3
Department of Orthopaedic Surgery, School of Medicine, Keio University, Tokyo, Japan
4
Department of Orthopaedic Surgery, Iwate Medical University, Morioka, Japan
5
Department of Orthopaedic Surgery, Mie University Faculty of Medicine, Tsu, Japan
6
Department of Orthopaedic Surgery, Suzuki Hospital, Tokyo, Japan
7
Department of Japanese Linguistics, Faculty of Education, Hirosaki Univerisity, Hirosaki, Japan
8
Department of Orthopaedic Surgery, Hamamatsu University School of Medicine, Hamamatsu, Japan
2

Abstract
Background. The Disability of the Arm, Shoulder and Hand
(DASH) questionnaire is a region-specific self-administeredquestionnaire that consists of a disability/symptom (DASHDS) scale, and two optional modules, the work (DASH-W)
and the sport/music (DASH-SM) modules. The DASH wascross-culturally adapted and developed by the Impairment
Evaluation Committee, Japanese Society for Surgery of theHand. The purpose of this study was to test the reliability,
validity, and responsiveness of the Japanese version of DASH(DASH-JSSH).
Methods. A series of 72 patients with upper extremity
disorders completed the DASH-JSSH, the medical outcomes
study 36-item short-form health survey (SF-36), and theVisual Analog Scale (VAS) for pain. Thirty-eight of thepatients were reassessed for test-retest reliability 1 or 2 weeks
later. Reliability was investigated by reproducibility and internal consistency. To analyze the validity, a principal component analysis and correlation coefficients between the
DASH-JSSH and the SF-36 were obtained. Responsivenesswas examined by calculating the standardized response mean
(mean change/SD) and effect size (mean change/SD of baseline value) after carpal tunnel release of the 17 patients withcarpal tunnel syndrome.
Results. Cronbach’s alpha coefficients in the DASH-DS andDASH-W were 0.962 and 0.967, respectively. The intraclasscorrelation coefficients for the same were 0.82 and 0.85, respectively. The unidimensionality of the DASH-DS andDASH-W were confirmed. The correlations between the
DASH-DS score and the subscale of the SF-36 scale ranged
from -0.29 to -0.73. The correlation coefficient between the
DASH-DS and the DASH-W was 0.79. The standardized response mean/effect size of DASH-DS, DASH-W, and VAS
for pain were -0.48/-0.26, -0.68/-0.41, and -0.40/-0.40, re-Offprint requests to: S. Toh
Received: March 11, 2005 / Accepted: May 13, 2005

spectively. DASH-DS and DASH-W were as moderately sensitive as VAS for pain.
Conclusion. The DASH-DS and DASH-W Japanese version
have evaluation capacities equivalent to those of the original
and other language versions of the DASH.

Introduction
Upper extremity disorder can limit the activities of sufferers and have negative effects on their quality of life
(QOL) and work activity. It is a common disorder and acostly health problem in the general population and in
the workplace.1,2 Numerous epidemiological studies aswell as those on psychosocial factors of upper extremity
disorders in the workplace have been systematically reviewed and summarized.1,2
Health status is an important patient outcome used toevaluate medical (especially surgical3) intervention
and in ergonomic studies.4 Several measures for theevaluation of upper extremity function have beendeveloped.5–10 Most of them are joint-specific5,10 ordisease-specific.7,8 Others are intended to evaluate thefunction of the entire upper extremity using a regionspecific measure.6,9 The Disability of the Arm, Shoulder,and Hand (DASH) questionnaire was devised as aregion-specific measure by the American Academy of
Orthopaedic Surgeons (AAOS) in collaboration with anumber of other organizations.6 The rationale for use ofthis measure is that the upper extremity is a functional
unit or kinetic chain.11 Therefore, the DASH is suitable
for measuring health status outcome because it ismainly a measure of disability.
The DASH is now available in several languages,12–18
and studies of its reliability and validity have been pub-

354

lished for not only the original version3 but also for the
Swedish,12 German,14 Spanish,15 Dutch,16 Italian,17 andChinese18 versions. However, one of the optional
DASH modules, the work module, has not been studied
except in the Italian and Chinese versions.17,18 We, theImpairment Evaluation Committee (Japanese Society
for Surgery of the Hand), have completed cross-cultural
adaptation and developed the DASH Japanese version(DASH-JSSH). The purpose of this study was to test
the reliability, validity, and responsiveness of the
DASH-JSSH (including the work module) and to makethe DASH-JSSH available for use in Japan.

Material and methods
In accordance with published guidelines,19,20 weorganized the DASH-JSSH committee consisting oftranslators, researchers, a methodologist, and aJapanese-language expert.
Adaptation process
The English version of the DASH (version 2.0) wastranslated into Japanese by two translators whose first
language was Japanese. One of them had no medical
background, and the other did. Their two “forward”
translations were synthesized into one after being reviewed and discussed by the committee. This Japaneseversion (prefinal version) was translated back into
English by two other translators whose first language
was English. One of them was blinded to the concepts
being investigated and had no medical background. The
other had a medical background. We collected pilot test
data and submitted it with the DASH-JSSH (prefinal
version) to the AAOS in 2002. They suggested that the
DASH-JSSH (prefinal version) needed to be modified
in terms of cultural adaptation. Following their suggestions, our committee modified the DASH-JSSH
prefinal version into a new, final version. The final
DASH-JSSH version was then evaluated with regard toreliability, validity, and responsiveness.
DASH questionnaire
The main part of the DASH is a 30-item disability/
symptom (DASH-DS) scale concerning the patient’s
upper extremity.3,6 Each item has five response choices,
ranging from “no difficulty or no symptom” to “unable
to perform activity or very severe symptom.” It is scoredon a scale of 1–5. The items ask about the severity ofeach of the symptoms of pain, activity-related pain, tingling, weakness, and stiffness (five items: numbers 24–28); the degree of difficulty when performing various
physical activities because of an arm, shoulder, or hand

T. Imaeda et al.: Japanese version of DASH

problem (21 items: numbers 1–21); the effect of theupper extremity problem on social activities, work, andsleep (three items: numbers 22, 23, 29); and the psychological effect on self-image (one item: number 30).
These provide the DASH disability/symptom (DASHDS) score ranging from 0 (no disability) to 100 (theseverest disability), after summation of the scores fromall items and transformation.
The DASH also contains two optional modules concerning the ability to work and the ability to perform
sports or play musical instruments. These two optional
modules each consists of four items, each of which is
rated on a scale of 1–5. These provide the DASH work
(DASH-W) score and the DASH sport/music (DASHSM) score ranging from 0 (no disability) to 100 (theseverest disability) after summation of the scores fromall items and transformation.
Patients and setting
A series of 73 patients with upper extremity disorders
were seen on an outpatient basis in five orthopedic surgery departments in Japan. Exclusion criteria were age
below 18 years and relevant co-morbidity (e.g., connective tissue disease). One patient with a co-morbidity ofsystemic lupus erythematosus (SLE) was excluded. The
study was thus conducted on 72 patients (17 men, 55
women) who were suffering from carpal tunnel syndrome (38 patients), rotator cuff disease (10 patients),
cubital tunnel syndrome (7 patients), thoracic outlet
syndrome (4 patients), or other problems (13 patients).
The mean age was 54.1 years (SD 14.9 years, range 20–
81 years). After informed consent was obtained fromthe patients to participate in this study, they answered
the questionnaire. The DASH-JSSH questionnaire, theofficial Japanese version of the 36-item short-form
health survey (SF-36, version 1.2)21,22 and the Visual
Analog Scale (VAS) (0–10 scale) for pain. The datacollected from the 72 patients were used as a baseline
value. Among the 72 patients, the 38 who had notherapy during the consecutive outpatient visits were
readministered the DASH-JSSH questionnaire and
VAS for pain 1 or 2 weeks later. The 17 patients withcarpal tunnel syndrome who underwent carpal tunnel
release by three hand surgeons answered the DASHJSSH questionnaire and the VAS for pain twice
preoperatively and postoperatively (3 months after surgery). The protocol of this study was reviewed and approved by the institutional review board prior to this
implementation.
Assessment of reliability, validity, and responsiveness
Reliability was investigated by looking at the reproducibility and internal consistency based on the test-retest

T. Imaeda et al.: Japanese version of DASH

method. The following analysis was conducted to examine the validity. A principal component analysis was
conducted to examine the construct validity and theunidimensionality of the DASH-JSSH disability/
symptom (DASH-JSSH-DS) and DASH-JSSH work
(DASH-JSSH-W) scales. Completeness of item responses of the DASH-JSSH and VAS for pain was
examined. Correlation coefficients between the
DASH-JSSH and the SF-36 were obtained, and the following hypotheses were examined to investigate concurrent validity: (1) “Physical functioning” (SF-36-PF)
or “role-physical” (SF-36-RP) would exhibit the strongest association. (2) “Bodily pain” (SF-36-BP) would
exhibit the next strongest association. (3) “Mental
health” (SF-36-MH) and “vitality” (SF-36-VT) would
exhibit the weakest association.
Correlation coefficients between the DASH-JSSHDS and the DASH-JSSH-W or the DASH-JSSH sport/
music (DASH-JSSH-SM) scales were also obtained.
Correlation coefficients between the DASH-JSSHDS and the SF-36 were obtained. Correlation coefficients between the DASH-JSSH and VAS for pain wereobtained, and the criterion-based validity investigation
looked at the following hypothesis: The correlation between the DASH-JSSH and VAS for pain would behigh. The responsiveness was examined by calculating
the standardized response mean (SRM) (mean change/SD)23 and effect size (mean change/SD of baseline
value)24 after carpal tunnel release of the patients withcarpal tunnel syndrome.

355

Results
Completeness of item responses
No patients had difficulty completing the DASH-JSSH
questionnaire. It took them 8 min 1 s, on average, tofinish the questionnaire: 95% confidence interval (95%
CI): 7 min 2 s to 9 min 1 s. Most of the patients considered all the items of the DASH-JSSH-DS section to beclear. Of the 72 patients, 9 (nonrespondent group) did
not answer one or more items of DASH-JSSH-DS.
None of them failed to answer more than three items.
Seven patients did not answer item 21 regarding sexual
activity. Three patients did not respond to item 19. Five
patients did not respond to items 2, 7, 8, 18, and 25, witheach item unanswered by one of them. The mean age(64 ± 12 years) of the nonrespondent group (n = 9)
was significantly higher than the mean age (53 ± 15
years) of the respondent group (n = 63) who completed
all the items (P = 0.038). Of the 72 patients, 55 (76%)
answered the DASH-JSSH-W. However, only 15 of
the 72 (21%) patients responded to the DASH-JSSHSM.
The mean DASH-JSSH scores, mean SF-36 subscalescores, mean VAS, and their ranges are shown in Table
1. The numbers of ceiling and floor scores of the DASHJSSH questionnaire, SF-36 subscales and VAS are
shown in Table 2. No patients recorded the minimum
disability score of 0 on the DASH-JSSH-DS (ceiling) or
the maximum disability score of 100 on the DASH-

Statistical analysis
Kolmogorov-Smirnov and Liliefors probability tests
were used to assess distribution of the DASH-JSSH,
SF-36, VAS for pain, ages of the subjects, time required
to fill out the questionnaires of the DASH-JSSH and
SF-36. The interval measurements [DASH-JSSH-DS,
DASH-JSSH-SM, SF-36-BP, general health subscale ofSF-36 (SF-36-GH), SF-36-VT, SF-36-MH, VAS, age,time required], were normally distributed, and therefore correlation was assessed using a parametric test
(Pearson’s correlation). The other interval measurements [DASH-JSSH-W, SF-36-PF, SF-36-RP, social
functioning subscale of SF-36 (SF-36-SF) and roleemotional subscale of SF-36 (SF-36-RE)] were notnormally distributed, and therefore correlation was assessed using a nonparametric test (Spearman’s correlation). Crohnbach’s alpha was used to assess internalconsistency. Instrument test-retest reliability was assessed with the intraclass correlation coefficient (ICC).
All statistical analyses were conducted using the Statistical Package for Social Science (SPSS) version 12.0J
software. The critical values for significance were set at
P < 0.05.

Table 1. Scores for DASH-JSSH, SF-36, and VAS
Score
Instrument

No.

Mean (SD)MedianRange

DASH-JSSH-DS
DASH-JSSH-W
DASH-JSSH-SM
SF-36-PF
SF-36-RP
SF-36-BP
SF-36-GH
SF-36-VT
SF-36-SF
SF-36-RE
SF-36-MH
VAS [0–10]

72
55
15
72
72
72
72
72
72
72
72
72

28 (21)33 (32)47 (43)72 (24)48 (41)47 (23)50 (21)56 (25)76 (26)55 (43)61 (25)4.7 (2.8)

25
25
44
80
50
42
49
57
88
67
60
5.0

3–93
0–100
0–100
0–100
0–100
0–100
5–97
0–100
13–100
0–100
8–100
0–10

DASH-JSSH-DS, disability/symptom scale of DASH-JSSH; DASHJSSH-W, work module of DASH-JSSH; DASH-JSSH-SM, sport/music module of DASH-JSSH; SF-36-PF, physical functioning subscaleof the 36-item Short-Form Health Survey (SF-36); SF-36-RP, rolephysical subscale of SF-36; SF-36-BP, bodily pain subscale of SF-36;
SF-36-GH, general health subscale of SF-36; SF-36-VT, vitality
subscale of SF-36; SF-36-SF, social functioning subscale of SF-36; SF36-RE, role-emotional subscale of SF-36; SF-36-MH, mental healthsubscale of SF-36; VAS [0–10], Visual Analog Scale for pain [0–10
scale]

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T. Imaeda et al.: Japanese version of DASH

Table 2. Ceiling and floor scores for DASH-JSSH, SF-36, and
VAS
Instrument scale

No.

No.
ceiling scoresa

No.
floor scoresb

DASH-JSSH-DS
DASH-JSSH-W
DASH-JSSH-SM
SF-36-PF
SF-36-RP
SF-36-BP
SF-36-GH
SF-36-VT
SF-36-SF
SF-36-RE
SF-36-MH
VAS [0–10]

72
55
15
72
72
72
72
72
72
72
72
72

0
12 (22%)4 (27%)
4 (6%)
18 (25%)3 (4%)0
1 (1%)
31 (43%)29 (41%)2 (3%)
4 (6%)0
3 (6%)
4 (27%)
1 (1%)
24 (34%)2 (3%)0
2 (3%)
0
23 (32%)0
2 (3%)aMaximum health status scoresb
Minimum health status scores

JSSH-DS (floor). Twelve and four patients had the
maximum scores, and three and four patients had
the minimum scores, for the DASH-JSSH-W and the
DASH-JSSH-SM, respectively.
Reliability
Internal consistency was assessed by use of Cronbach’s
alpha coefficient. The alpha coefficient for the 30 itemsin the DASH-JSSH-DS was high (0.962). When thealpha coefficient was calculated for each of the 30 items
by eliminating each item, one by one, the range was
0.959–0.963; and no items were found to change theinternal consistency substantially. The alpha coefficients for the four items in the DASH-JSSH-W andDASH-MS were also high (0.967 and 0.985, respectively). When the alpha coefficients were calculated foreach of the four items by eliminating each item, one byone, the ranges were 0.952–0.963 and 0.971–0.989, respectively. No items were found to change the internalconsistency substantially.
Instrument test-retest reliability was assessed with
the intraclass correlation coefficient (ICC). There were
38 patients for the test-retest reliability, and the period
between the first and second tests was a mean of 9.2
days (range 6–17 days). The ICC for the DASH-JSSHDS was 0.82 (95% CI 0.69–0.90). The ICCs for the
DASH-JSSH-W and DSSH-JSSH-SM were 0.85 (95%
CI 0.70–0.93) and 0.91 (95% CI 0.64–0.98), respectively.
All ICCs for the DASH-JSSH indicate sufficient
reproducibility.
Validity
A principal component analysis was conducted to confirm the unidimensionality of the DASH-JSSH-DS. The

Fig. 1. Scree plot of the principal components in the disability/
symptom scale of Disability of the Arm, Shoulder, andHand — Japanese Society for Surgery of the Hand (DASHJSSH-DS)

first factor had an eigenvalue (amount of variation in
the total sample accounted for by that factor)16 of 14.65,
which explained the 49% total variance of the DASHJSSH-DS scores of the patients. The unidimensionality
was found to be strong as a result of a substantial difference between the first and the second factors(eigenvalue 2.80) (Fig. 1). When looking at the first
factor loading for each item, all items except item 24
exhibited loading (the correlation with the total score)of 0.4 or higher (Table 3) and communalities of morethan 0.6, except question 30 (communality 0.47). The
unidimensionality of the DASH-JSSH-W was also
confirmed by a principal component analysis. The
eigenvalue for the first factor was 3.652, which explained the 91% total variance of the DASH-JSSH-W
scores of the patients. Furthermore, the unidimensionality of the combined items for the DASHJSSH-DS and the DASH-JSSH-W was also confirmed
by a principal component analysis (Fig. 2). The
eigenvalue for the first factor was 17.94, which explained the 53% total variance of the combined scoresof the patients. The unidimensionality was found to bestrong as a result of a substantial difference between thefirst and second factors (eigenvalue 2.68). All combined
items exhibited first loading (the correlation with thetotal score) of more than 0.4 and communalities of morethan 0.7.
The correlations between the DASH-JSSH-DS score
and the subscales of the SF-36 scale ranged from -0.29
to -0.73 (Table 4). The strongest correlation was observed in “role-physical” followed by “physical functioning” and “bodily pain.” The correlation between
DASH-JSSH-DS and “mental health” or “vitality” wassomewhat weak. These results support the hypothesis
set down in advance except the strongest correlation(Table 4). Correlation coefficients between the DASH-

T. Imaeda et al.: Japanese version of DASH

357

Table 3. Factor loading (unrotated) of principal components
of DASH-JSSH-DS
Item no.

Loading

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30

0.631
0.707
0.752
0.770
0.817
0.763
0.814
0.843
0.820
0.683
0.797
0.831
0.767
0.731
0.632
0.702
0.745
0.722
0.759
0.585
0.708
0.621
0.787
0.323
0.404
0.612
0.667
0.497
0.545
0.606

Fig. 2. Scree plot of the principal components in combined
items of DASH-JSSH-DS and the work module of DASHJSSH (DASH-JSSH-W)

JSSH-DS and the DASH-JSSH-W or the DASH-JSSHSM were 0.79 and 0.82, respectively (Table 4) (P < 0.01).
These results indicate strong correlations between the
DASH-JSSH-DS and the DASH-JSSH-W and between
the DASH-JSSH-DS and the DASH-JSSH-SM.

The correlations between the DASH-JSSH-W score
and the subscales of the SF-36 scale ranged from -0.38
to -0.77 (Table 4). These correlations were similar tothe correlations between the DASH-JSSH-DS score
and the subscales of the SF-36 scale. The correlations
between the DASH-JSSH-SM score and the subscalesof the SF-36 scale were weak and ranged from 0.12
to -0.65 (Table 4).
No statistical difference in age was found between
men and women (P = 0.161). The DASH-JSSH-DS
mean score was 49.9 (SD 4.7) for men and 55.4 (SD 1.8)
for women. There was no statistical difference between
them (P = 0.194). This result supports our hypothesis.
The correlation between the DASH-JSSH-DS scoreand age was weak (r = 0.296, P < 0.05).
The correlation between the DASH-JSSH-DS score
and the degree of pain was examined and observed asmoderate for the SF-36 bodily pain score and the VAS
for pain (Table 4). The correlation between the DASHJSSH-W score and the degree of pain was also examined and observed as moderate for the SF-36 bodily
pain score and the VAS for pain (Table 4).
ResponsivenessOf 38 patients with carpal tunnel syndrome, 17 underwent carpal tunnel release. They completed the DASHJSSH and VAS for pain 3 months after the surgery. The
mean subject age was 57 years (SD 10 years; range 48–
78 years). There were 16 females and one male. Of the
17 patients, 13 completed the DASH-JSSH-W, andthose scores were included for this study. On the other
hand, only 3 of the 17 patients completed the DASHJSSH-SM, so this score was excluded for this study. All
scores for DASH-JSSH-DS, DASH-JSSH-W, and VAS
for pain were normally distributed. The calculated SRM
and effect size of DASH-JSSH-DS, DASH-JSSH-W,
and VAS for pain were -0.48/-0.26, -0.68/-0.41, and-0.40/-0.40, respectively. There was no statisticaldifference between the mean values of preoperativeand postoperative DASH-JSSH-DS scores (P = 0.068).
There was a statistical difference between the meanvalues of preoperative and postoperative DASH-JSSHW scores (P = 0.030). There was no statistical difference
between the mean value of preoperative and postoperative VAS scores for pain (P = 0.119). DASH-JSSH-DS
and DASH-JSSH-W were as moderately sensitive as
VAS for pain.

Discussion
Japanese adaptation of the DASH questionnaire was
performed following a systematic standardized approach.19,20 The purpose of this study was to examine the358

T. Imaeda et al.: Japanese version of DASH

Table 4. DASH-JSSH, SF-36, VAS, and their correlations
Correlation coefficients with
Instrument scale

No.

DASH-JSSH-DS‡

DASH-JSSH-W#

DASH-JSSH-SM‡DASH-JSSH-DS‡
DASH-JSSH-W#
DASH-JSSH-SM‡
SF-36-PF#
SF-36-RP#
SF-36-BP‡
SF-36-GH‡
SF-36-VT‡
SF-36-SF#
SF-36-RE#
SF-36-MH‡
VAS [0–10]‡

72
55
15
72
72
72
72
72
72
72
72
72

—
0.79**
0.82**-0.62**-0.73**-0.61**-0.44**-0.36**-0.29**-0.53**-0.38**
0.47**——
0.58*-0.45**-0.77**-0.47**-0.52**-0.42**-0.38*-0.55**-0.42**
0.64**———-0.65**-0.72**
-0.24
0.19
-0.15
0.12
-0.04
-0.17
0.45

* P < 0.05; ** P < 0.01; ‡ Pearson’s correlation; # Spearman’s correlation

psychometric qualities of the DASH-JSSH by assessing
its psychometric standards in the area of the reliability,
validity, and responsiveness.
The DASH-JSSH consists of a 30-item scale and two
optional 4-item scale modules. It took patients a similar
amount of time to complete the DASH-JSSH comparedwith the time to complete the other language versions.13
This indicated that the questionnaire was easy to understand. Elderly patients left no more than three items
unanswered, and those were thought to be pertaining to
specific activities, such as sexual and recreational activities, not performed by those individuals.
The lack of floor and ceiling effects assure the authorsof the validity of this version of the DASH-JSSH-DS.
The validation process of the DASH-JSSH scale has
shown that it has reliability similar to that of the otherlanguage versions12–18 including the original one.25 This
scale, as was the original DASH scale, was developed
for clinical assessment of a patient group, not of individual patients.22 Internal consistency needs to behigher than 0.95 if a scale is to be used for tracking
individual patients.26 Most translated versions of theDASH12,14–17 and the original one6 had internal consistency higher than 0.95. Thus, most language versions of
the DASH, including the Japanese version, could be
used with caution for daily assessment of individual
patient status over time.
The validation process of the DASH-JSSH questionnaire has shown that it has validity similar to that of theother language versions,12,14–18 including the original
DASH.25 The strong correlations between the DASHJSSH-DS and SF-36 subscales (role of physical health,physical functioning, and bodily pain) support this validity and demonstrate results similar to those of thevalidation papers for the other language versions including the original DASH.
The strong correlations between the DASH-JSSH-W
and SF-36 subscales (role of physical health, physicalfunctioning, and bodily pain) support this validity anddemonstrate results similar to those of the validation
paper for the Italian version.17 The correlations between
the DASH-JSSH-SM and SF-36 subscales were weakand demonstrated results similar to those of the validation paper for the Italian version17 because of the small
sample size. This area needs further investigation.
These results demonstrated that the DASH-JSSH(especially DASH-JSSH-DS and DASH-JSSH-W)
measures the important elements that make up healthrelated QOL.
The DASH-JSSH-DS scale exhibited high unidimensionality, and there was no low item-scale correlation. These results were similar to those of the
Dutch version.16 The DASH-JSSH-W scale also exhibited high unidimensionality, and there was no low itemscale correlation. The communalities of these two scales(DASH-JSSH-DS and DASH-JSSH-W) were high.
These results show that the DASH-JSSH-W has a highquality of validation.
Cohen’s rule-of-thumb for interpreting the “effectsize index” — a value of 0.2 is small, 0.5 is moderate,
and 0.8 or greater is large — can be applied to theSRM.23 The responsiveness of the DASH-JSSH-DS andDASH-JSSH-W for the patients with carpal tunnel syndrome was moderate 3 months after carpal tunnel release operation, although other studies showed a higher
responsiveness of the DASH-DS than our results.27
There was no statistical difference between the meanvalue of preoperative and postoperative DASH-JSSHDS scores. This is thought to be due to the small sample
size and requires further investigation.
We believe the strengths of this study are that the
DASH-JSSH-W and DASH-JSSH-DS scales demonstrated good reproducibility, consistency, and validity.
Moreover, both of them had moderate responsiveness.
A limitation of this present study is that we cannot
successfully validate the DASH-JSSH-SM because theT. Imaeda et al.: Japanese version of DASH

sample size was relatively small and the patient’s response rate was low. The samples of this study are notrepresentative of the general population.

Conclusions
We have concluded that the DASH-DS and DASH-W
Japanese version have evaluation capacities equivalent
to those of the other language versions of the DASH.
We expect that use of these scales in Japan to assess
treatment by the patients themselves will contribute tomeaningful improvement of outcome for patients withupper extremity disorders.

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